Neurocognitive Disorders

Match each clinical vignette with the most likely underlying neurocognitive diagnosis.

Match each clinical vignette describing a patient with progressive cognitive decline to the most likely underlying neurocognitive disorder diagnosis.

An internal medicine physician is evaluating a 76-year-old male patient who presents with his daughter due to concerns about his worsening memory and unusual behavior over the past 14 months. The daughter reports that his cognitive abilities fluctuate drastically; on some days he is highly conversational and independent, while on other days he stares blankly for hours and requires help with dressing. He frequently reports seeing "small animals" hiding in the corners of his room. His medical history includes hypertension, benign prostatic hyperplasia, and Bipolar I disorder. He discontinued his mood stabilizer 5 years ago against medical advice but has remained euthymic since. Current medications include amlodipine, tamsulosin, and carbidopa-levodopa, which was initiated two months ago by a neurologist for a newly developed resting tremor and bradykinesia.

The patient's daughter is his legally appointed healthcare proxy via a verified advance directive. However, his estranged son is also present at the visit and demands that the physician immediately prescribe a strong medication to "stop the crazy visions," explicitly overriding his sister's request for a cautious approach.

On mental status examination, the patient is alert but oriented only to person. He scores $19/30$ on the Montreal Cognitive Assessment, with pronounced deficits in visuospatial function and executive tasks. Physical examination reveals bilateral cogwheel rigidity in the upper extremities.

Which of the following is the most appropriate next step in the management of this patient?

A 78-year-old man is hospitalized for community-acquired pneumonia. On the evening of hospital day 3, he becomes acutely confused, agitated, and combative towards nursing staff. He attempts to pull out his intravenous line, claiming that "snakes are biting his arm." His baseline cognitive function is intact. Arrange the following interventions for managing this patient's acute agitation in the correct escalating sequence, from the initial preferred approach to the absolute last resort.

An 82-year-old retired pilot is currently admitted to the surgical ward on post-operative day three following an open reduction and internal fixation of a right femoral neck fracture. The on-call physician is paged urgently by the nursing staff because the patient has suddenly become highly disoriented, verbally aggressive, and is actively attempting to remove his peripheral intravenous catheter and surgical dressings. His baseline cognitive status prior to admission was completely intact.

Arrange the following clinical actions in the most appropriate sequential order for the evaluation and management of this patient's acute behavioral decompensation.

An 81-year-old retired teacher is accompanied to the outpatient geriatrics clinic by her daughter. The daughter reports that over the past six to nine months, the patient has become increasingly forgetful and struggles to plan her usual weekly garden club meetings. Furthermore, the patient has recently stopped visiting her friends because she is embarrassed by frequent episodes of urinary incontinence. When asked about her mobility, the patient states, 'My feet feel like they are stuck to the ground.' Medical history is significant for well-controlled type 2 diabetes mellitus and mild osteoarthritis. Vital signs are within normal limits. Neurologic examination reveals a wide-based, slow, shuffling gait, but there is no resting tremor, cogwheel rigidity, or bradykinesia of the upper extremities. Cognitive testing reveals prominent deficits in executive function and attention. Which of the following is the most likely diagnosis?

Match each distinct clinical presentation with the most likely underlying neurocognitive etiology.

A 74-year-old man with a 9-year history of Parkinson disease and emerging cognitive decline is brought to the emergency department by his daughter due to acute-onset, severe agitation and frightening visual hallucinations over the past 48 hours. He states that strangers are hiding in his room. His current medication regimen includes carbidopa-levodopa, pramipexole, and trihexyphenidyl. Arrange the following steps in the correct clinical escalation sequence for the evaluation and management of this patient's acute neuropsychiatric presentation, moving from initial assessment to therapies for refractory symptoms.

A $75$-year-old man is brought to the clinic by his daughter due to a progressive decline in his mobility and memory over the past $8$ months. The daughter reports that he has become increasingly forgetful and struggles to manage his finances. Additionally, his walking has become remarkably slow and unsteady; he walks with his feet spread apart and appears as if his shoes are 'stuck to the floor.' In the past month, he has had several episodes of urinary incontinence, which he seems largely unconcerned about. His medical history includes hypertension and osteoarthritis. Neurological examination reveals a wide-based, magnetic gait with short steps. Muscle strength and deep tendon reflexes are normal, and there is no resting tremor or cogwheel rigidity. Montreal Cognitive Assessment score is $21/30$. Which of the following is the most appropriate next step in the diagnostic workup?

During a routine home-visit evaluation, a geriatric psychiatrist examines a 73-year-old man whose daughter reports a 9-month history of progressive cognitive decline and unusual behaviors. The daughter emphasizes that his mental clarity fluctuates dramatically; he can be highly alert in the morning but profoundly lethargic and disorganized by the afternoon. Over the past 3 months, he has started seeing "strangers sitting on the living room couch," which causes him significant distress and agitation. For the past 4 years, he has exhibited violent thrashing and shouting movements during sleep. His medical history is significant for major depressive disorder, for which he has taken fluoxetine continuously for the last 5 years. Vital signs are within normal limits. Neurologic examination demonstrates bilateral cogwheel rigidity and a mild resting tremor in the left upper extremity. His Montreal Cognitive Assessment score is 20/30, featuring prominent deficits in visuospatial construction. The physician discusses management options with the daughter to address the patient's distressing visual hallucinations. Which of the following is the most appropriate next step in the pharmacologic management of this patient's condition?

A primary care physician is evaluating a 71-year-old retired mechanic who is accompanied by his son. The son reports that over the past 14 months, his father has exhibited progressive short-term memory loss, missed several bill payments, and recently struggled to recall the names of his grandchildren. The patient feels he is "doing just fine" and is mildly annoyed by the visit. Vital signs are normal, and the neurological examination is nonfocal. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for evaluating and managing this patient's suspected major neurocognitive disorder, from initial clinical assessment to definitive management.

A 76-year-old retired architect is brought to the clinic by his son. Over the past $8$ months, the patient has experienced a progressive decline in his cognitive abilities. His son notes that the patient's alertness fluctuates significantly from day to day; he sometimes stares blankly for several minutes during conversations. The patient also frequently reports seeing unfamiliar children playing in his living room, though he is not distressed by their presence. His medical history includes major depressive disorder, for which he has taken fluoxetine for $5$ years. Vital signs are within normal limits. Neurological examination reveals a resting tremor in the left hand, symmetric rigidity, and a slow, shuffling gait. The Montreal Cognitive Assessment (MoCA) score is $19/30$. Laboratory studies show:

Thyroid-stimulating hormone (TSH): $2.4 \text{ \mu U/mL}$ (normal: $0.4-4.0 \text{ \mu U/mL}$)
Free thyroxine (T4): $1.3 \text{ ng/dL}$ (normal: $0.9-2.4 \text{ ng/dL}$)

The son is overwhelmed by the recent changes and demands that his father be admitted to a locked psychiatric facility immediately. However, the patient's previously executed advance directive designates his wife as the healthcare proxy and expresses a clear preference for home-based care.

Which of the following is the most appropriate next step in the management of this patient?

An 80-year-old man, a former university professor, visits his outpatient provider accompanied by his daughter. She expresses concern that over the past 18 months, he has been repeatedly misplacing important documents, forgetting appointments, and struggling to manage his finances. Last week, he was found wandering several blocks from his house, unable to remember the route back. Vital signs are stable, and the neurological examination shows no focal deficits. The provider plans a comprehensive evaluation and anticipates a long-term management strategy for presumed Alzheimer disease.

Arrange the following clinical steps in the appropriate chronological sequence for the standard diagnostic evaluation and progressive longitudinal management of this patient's condition.

Match the following clinical vignettes to the most likely underlying neurocognitive disorder etiology.

A $68$-year-old man is brought to the emergency department by his wife due to severe muscle stiffness, fever, and marked confusion over the past $48$ hours. Over the past $14$ months, the patient has experienced progressive cognitive decline, prominent day-to-day fluctuations in alertness, and vivid, recurrent visual hallucinations of people in his house. His wife notes that he often thrashes and punches his pillows while asleep. His past medical history is significant for major depressive disorder. Current medications include a daily multivitamin and citalopram. Three days ago, a covering physician prescribed haloperidol to manage the patient's distressing hallucinations. On examination, his temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $118\text{ /min}$, and blood pressure is $168/102\text{ mm Hg}$. He is diaphoretic and disoriented. Neurologic examination reveals profound "lead-pipe" muscle rigidity in all extremities. Deep tendon reflexes are $1+$ bilaterally, and there is no clonus. Laboratory studies show a creatine kinase of $4,500\text{ U/L}$, a TSH of $3.5\text{ mU/L}$ (normal: $0.5-5.0\text{ mU/L}$), and a free T4 of $1.2\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$). Which of the following is the most likely cause of this patient's acute presentation?

An 82-year-old man with a history of mild Alzheimer dementia is hospitalized for a urinary tract infection. On hospital day 2, he becomes acutely agitated, disoriented, and begins pulling at his intravenous lines. He is experiencing visual hallucinations and yelling at the nursing staff. Arrange the following interventions in the most appropriate sequential order of escalation, from initial best practices to interventions of absolute last resort, for the management of this patient's acute delirium with severe agitation.

During a specialized memory disorders conference, a panel of neurologists and psychiatrists discusses five complex patient cases to highlight the diverse pathophysiology of neurodegenerative conditions. For each patient vignette described below, identify and match the correct specific neurocognitive disorder diagnosis.

A 58-year-old man is brought to the physician by his wife due to profound changes in his behavior over the past 12 months. His wife states that he was previously a reserved and empathetic middle school teacher, but he recently began making sexually explicit comments to strangers at the grocery store. He has also developed a habit of eating exclusively sugary cereals and frequently takes food from the plates of other patrons at restaurants. When confronted about these actions, the patient is apathetic and demonstrates no remorse. His medical history is significant for hyperlipidemia. Vital signs are within normal limits. On mental status examination, he is alert and oriented to person, place, and time. He scores 26/30 on the Montreal Cognitive Assessment, primarily losing points on verbal fluency and abstraction. Memory recall is intact. Neurological examination reveals a positive grasp reflex but is otherwise unremarkable. Which of the following is the most likely diagnosis?

Match each patient's clinical presentation with the most likely corresponding neuroimaging or ancillary diagnostic finding.

Pair the following clinical presentations with the most likely corresponding neurocognitive disorder.